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Intracytoplasmic sperm injection (ICSI) can be used as part of an in vitro fertilisation (IVF) treatment to help you and your partner conceive a child.

ICSI is the most successful form of treatment for men who are infertile and is used in nearly half of all IVF treatments (HFEA 2016).

ICSI only needs one sperm, which is injected directly into the egg (HFEA 2016). The fertilised egg (embryo) is then transferred to your womb (uterus).

Could ICSI help us to conceive?

During ICSI the sperm doesn't have to travel to the egg or penetrate the outer layers of the egg. This means that it can help couples where the man's sperm:

can't get to the egg at all

or can get to the egg, but for some reason can't fertilise it

ICSI is likely to be recommended in the following circumstances:

A very low sperm count.

A high percentage of abnormally shaped or slow sperm.

Sperm that does not show in the fresh sample but can be collected from the testicles or from the duct where sperm is stored (epididymis). This may be needed if your partner has had an irreversible vasectomy or injury.

Problems with getting an erection and ejaculating, due to spinal cord injuries or diabetes, for example.

A need to use frozen sperm that is not of the best quality.

A need to test the embryos to avoid passing on a genetic abnormality.

(HFEA 2015)

If you have tried IVF, you may move on to ICSI if not enough eggs could be retrieved, or if eggs retrieved were not fertilised with IVF (HFEA 2015).

Although ICSI can improve the chances of fertilisation compared with IVF, it doesn’t guarantee that fertilisation will happen (HFEA 2015).

How is ICSI carried out?

As with standard IVF treatment, fertility drugs will be needed to stimulate the ovaries to develop several mature eggs for fertilisation. Your doctor will use ultrasound, and sometimes blood tests, to monitor this stage of your treatment (HFEA 2015). When your eggs are ready for collection, you and your partner will undergo separate procedures.

Your partner will be asked to produce a sperm sample himself, by ejaculating into a cup on the same day as your eggs are collected.

If there is no sperm in his semen, or he's unable to ejaculate, it may be possible for your doctor to extract sperm from him (NCCWCH 2013). For that procedure, the doctor will use a fine needle to take the sperm from your partner's:

epididymis, in a procedure known as percutaneous epididymal sperm aspiration (PESA), or

testicle, in a procedure known as testicular sperm aspiration (TESA)

(HFEA 2015)

This will usually be done under a local anaesthetic, so your partner won’t feel any pain.

If these techniques don't remove enough sperm, your doctor may take a biopsy of testicular tissue, which sometimes has sperm attached (HFEA 2015). This is called testicular sperm extraction (TESE) or micro-TESE, if the surgery is carried out with a microscope. This will usually be carried out under general anaesthetic.

For practical reasons, surgical sperm extraction from the epididymis or testicle is often carried out before the treatment cycle begins. The retrieved sperm are frozen. Any discomfort felt by your partner should be mild and can be treated with painkillers.

During egg retrieval you’re likely to be sedated but conscious (HFEA 2015, NCCWCH 2013). The doctor will remove your eggs using a fine, hollow needle, attached to an ultrasound probe. You'll be given progesterone in the form of a pessary, or an injection of progesterone gel to help the lining of your womb prepare for egg transfer (HFEA 2015, NCCWCH 2013). You may feel a bit bruised and sore after egg retrieval and have some light bleeding(HFEA 2015, NCCWCH 2013).

Meanwhile, an embryologist isolates individual sperm in the lab and injects them into your individual eggs. A day later, the fertilised eggs will have become embryos. The procedure then follows the same steps as in IVF. Your doctor will transfer one or two embryos into your womb, through the cervix, using a fine catheter (tube) usually guided by ultrasound (HFEA 2015).

Embryos can stay in the lab for up to six days, but may be transferred two days to three days after fertilisation or at five days after fertilisation (HFEA 2015). If transferred at five days, the embryo will be at the blastocyst stage. If you're just having one embryo transferred (called Elective Single Embryo Transfer, or eSET), having a blastocyst transfer can improve your chances of a successful, healthy, single baby (Glujovsky et al 2012, HFEA 2015, NCCWCH 2013).

The maximum number of embryos that can be transferred to your womb is two (NCCWCH 2013). If you're under 40 and a suitable candidate, you may be recommended for elective single embryo transfer (eSET) in your first and second cycles. If you have one or more top-quality embryos, eSET can increase your chance of having a healthy single baby at term (NCCWCH 2013).

If you're 40 or over you may be offered two embryos transferred per cycle, because you have a smaller chance of conceiving with your own eggs (NCCWCH 2013). If the eggs are donated, again only one or two can be transferred depending on the age of the donor and the quality of the embryos.

No matter what your age, if you have a top-quality blastocyst available, this may be transferred on its own, as this is your best chance for a healthy pregnancy (NCCWCH 2013). Extra good-quality embryos, if there are any, may be frozen in case this cycle isn't successful or for having another baby in the future (HFEA 2015).

If all goes well, an embryo will attach to the wall of your womb and continue to grow to become your baby. After about two weeks, you will be able to take a pregnancy test (NHS 2015A).

How long does ICSI treatment last?

One cycle of ICSI takes between four weeks and six weeks to complete. You and your partner can expect to spend a half-day at the clinic for the egg and sperm retrieval procedures. You will usually be asked to go back between two days and five days later for the embryo transfer procedure (HFEA 2015).

If you’re under 40, you should be offered up to three full cycles of IVF with or without ICSI. If you’re aged between 40 and 42 years old, you’ve never had IVF before and you have no sign of low egg numbers, you should be offered one full cycle after full discussion of the implications of IVF and pregnancy at this age (NCCWCH 2013, NHS 2015b).

What are the success rates of ICSI?

The fertilisation rate for ICSI may be higher than if you use conventional IVF methods, but the pregnancy rate with ICSI is the same as IVF pregnancy rates (NCCWCH 2013, NICE 2013):

What are the advantages of ICSI?

ICSI may give you and your partner a chance of conceiving your genetic child when other fertility treatments options are unlikely to do so (HFEA 2015, NCCWCH 2013).

If your partner is unable to ejaculate on the day of egg collection for standard IVF, sperm can instead be extracted for ICSI (NCCWCH 2013).

ICSI can also be used to help some couples with unexplained infertility. In this case however, your doctor is likely to initially recommend standard IVF, as ICSI and IVF pregnancy rates are very similar and IVF is a less complex treatment (NCCWCH 2013).

ICSI doesn't appear to have any effect on your child’s mental or physical development (NCCWCH 2013).

What are the disadvantages of ICSI?

ICSI has been in use for a shorter time than IVF. So experts are still learning about its possible effects.

ISCI carries the same risks associated with standard IVF procedures, such as ovarian hyperstimulation syndrome (OHSS), multiple pregnancy if more than one embryo is transferred, and ectopic pregnancy (HFEA 2015).

During natural conception, only the hardiest sperm manage to travel great distances and break through the membrane of an egg to fertilise it. Weaker sperm don't make it. But because ICSI bypasses this natural selection process, there's a slightly increased risk of rare genetic problems carried by the sperm being passed on to the child (Palermo et al 2015). Some but not all genetic problems can be tested for, before you have the treatment (HFEA 2015).

There is limited evidence that adult men who were conceived by ICSI have a lower sperm quantity and quality than men conceived naturally. However, more research is needed to confirm this finding (Belva et al 2016).

Rest assured that ultrasound scans during early pregnancy will monitor your baby's development (NHS 2015A). And if you have any worries, you will be able to talk to your doctor.

NHS. 2015b. Can I get IVF treatment on the NHS? NHS Choices, Health A-Z. www.nhs.uk [Accessed October 2016]

NHS. 2015. www.nhs.uk

NICE 2013. Assessment and treatment for people with fertility problems: information for the public. Last updated August 2016. National Institute for Health and Care Excellence. www.nice.org.uk [Accessed October 2016]

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